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A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
- A. Suggest the nurse manager as a witness.
- B. Agree to sign the document as a witness.
- C. Notify the provider of the client's request.
- D. Help the client find an unrelated third party.
Correct Answer: D
Rationale: An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client's signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the provider unless the absence of the advance directive interferes with client care.
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Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube. The nurse develops a care plan and should determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.
- A. The client is increasingly agitated.
- B. The client's left hand is pale and cold.
- C. The client's skin under the restraint is red.
- D. The client verbalizes the reason for the restraints.
- E. The client is unable to reach the gastrostomy tube with his or her hands.
- F. The client demonstrates behavior that includes biting the attending staff.
Correct Answer: A,B,C,F
Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client's inability to reach the gastrostomy tube with his or her hands are expected outcomes.
The nurse performing an admission assessment notes that a client has been prescribed metoclopramide for a prolonged period. The nurse should immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?
- A. Dry mouth
- B. Anxiety or irritability
- C. Excessive drowsiness
- D. Uncontrolled rhythmic movements of the face or limbs
Correct Answer: D
Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should call the primary health care provider because these adverse effects may be irreversible. The medication would be discontinued, and no further doses should be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.
The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client states to the nurse in confidence that the family members frequently hit him. Which therapeutic statement should the nurse communicate in response?
- A. I have a legal obligation to report this type of abuse.
- B. Let's get these treated, and I will maintain confidence.
- C. Let's talk about ways to prevent someone from hitting you.
- D. If this happens again, you must call the emergency department.
Correct Answer: A
Rationale: The nurse should inform the client that nurses cannot maintain confidence about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options 3 and 4 delay protective action and place the client at risk for future abuse.
A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statements exemplify correct documentation on the report? Select all that apply.
- A. The client fell out of bed.
- B. No bruises or injuries are noted on the client.
- C. The client apparently climbed over the side rails when the nurse was out of the room.
- D. The health care provider was notified that the client was found lying on the floor next to the bed.
- E. The client is alert and oriented and stated that he needed to 'go to the bathroom and didn't want to bother the nurse.'
- F. Vital signs are temperature: 98.6°F (37°C); pulse 78 beats per minute and regular; respirations 16 breaths per minute and regular; blood pressure 188/78 mm Hg.
Correct Answer: B,D,E,F
Rationale: An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant information. The primary health care provider is notified of the incident and completes the report after examining the client. Documentation on the report should always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse was out of the room.
The nurse should plan to wear this protective device when caring for hospitalized clients with which diagnosed disorders? (Refer to the figure.) Select all that apply.
- A. Scabies
- B. Tuberculosis
- C. Hepatitis A virus
- D. Pharyngeal diphtheria
- E. Streptococcal pharyngitis
- F. Meningococcal pneumonia
Correct Answer: D,E,F
Rationale: A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection. Droplet precautions refer to precautions used for organisms that can spread through the air but are unable to remain in the air farther than 3 feet. Many respiratory viral infections such as respiratory viral influenza require the use of a standard surgical mask when caring for the client. Some other disorders requiring the use of a standard surgical mask include pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps; pneumonia, including meningococcal pneumonia; and the pneumonic plague. Scabies and hepatitis A are transmitted by direct contact with an infected person and require the use of contact precautions for protection. Tuberculosis requires the use of airborne precautions and the use of an individually fitted particulate filter mask. A standard surgical mask would not protect the nurse from Mycobacterium tuberculosis.